Healthcare Provider Details

I. General information

NPI: 1811240674
Provider Name (Legal Business Name): REBECCA LYNN CRUM KOPPES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4065 N 35TH ST
MILWAUKEE WI
53216-1705
US

IV. Provider business mailing address

4065 N 35TH ST
MILWAUKEE WI
53216-1705
US

V. Phone/Fax

Practice location:
  • Phone: 414-445-9180
  • Fax:
Mailing address:
  • Phone: 414-445-9180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8293-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number128141121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: